Discussion:
Eagle’s syndrome, categorized initially by Dr. Watt Eagle, divides
patients into two groups based on the structures compressed or irritated
by the styloid complex. The classic form involves cranial nerves
5-trigeminal, 7-facial, 9-glossopharyngeal, and/or 10-vagus, where many
providers believe this neuralgia is a type of entrapment syndrome
involving the cranial nerves, commonly after tonsillectomy (18). The
vascular form involves the internal carotid artery (ICA), external
carotid artery (ECA) (15), periarterial sympathetic nerve plexus (19),
and the internal jugular vein (IJV) (20,21).
In our patient, we assume that the muscle relaxant weakened the normal
muscle tone and weakened its share in neck support. On the other hand,
SMT, even in the hands of experienced practitioners, has well-known
complications, particularly for the upper cervical segment. Lastly, and
the most important, from our perspective, is the presence of an
anomalous styloid process that caused the injury to ICA. So, SMT acted
as the trigger, firing the anomalous styloid process that acted, in
turn, as the bullet, causing injury in the ICA.
Many patients who unknowingly have Eagle’s syndrome pursue physical
therapy, massage, medical management, injections, and surgery (22). In
fact, practitioners of manipulation, irrespective of their professional
training, have consistently claimed that the risk of stroke after
manipulation is so small that it should be considered insignificant
(23,24). However, three studies described carotid artery dissection
and/or stroke after massage (25–27). Another three studies described
exercise produced adverse symptoms/events, including arterial dissection
(28–30). Another research recommends the avoidance of thrust
manipulation, along with relative contraindications for combined
flexion/rotation in patients with styloid anomalies, as this has led to
carotid dissection in several cases (31).
Our patient presented to us ten days after SMT, and this delay in
presentation is also noticed in other studies (6,32–36). Moreover, due
to the relative inaccessibility of the distal ICA, we chose the
endovascular choice as the endovascular management of carotid artery
injury had been previously studied and proved to be safe, effective, and
maybe even superior to surgery, particularly in zone I and III neck
injuries (37–40).